What Formula Feeding and Supplementing Mothers

Aren’t Hearing

Feed the Baby:

Photo by peasap, Flickr creative commons, 2008

I have nothing relevant to disclose

The Elephant in the Room

Why is an IBCLC covering this?

Healthy People 2020 Goals

Reasons Women Formula Feed or Supplement

Fein et al, J Am Diet Assoc, 1999

�  2, 5, and 7 month old babies �  >1000 formula fed infants in each age group � Sought to find out issues with infant feeding

and see if it correlated to increased diarrhea �  Found that:

�  33% of mothers mixed formula inappropriately � Education from health care professional may

help

Lambiner-Wolfe et al, Pediatrics, 2008 �  Goal was to assess what parents learn

about formula feeding practices �  77% of mothers did not learn about formula

prep from HCPs �  73% did not learn about storage from HCP �  Mothers thought ready to feed or powdered

formulas were “unlikely to contain germs” �  30% did not read some or all of the

instructions on the can

Renfrew et al, 2002, Archives of Diseases in Childhood � UK based � Systemic review �  Found only 5 quality studies �  Low numbers of participants � All of the studies found inaccuracies in

reconstitution

Herbold & Scott, 2008, International Journal of Environmental Health Research

�  15 mothers, infants under 7 months � Observer came to watch them

�  73% did not wash hands �  60% did not keep bottle cool during transport �  20% of infants slept with bottle �  47% added cereal to formula

Our Study � Qualitative � Mothers surveyed via internet � Youngest was 18; oldest was 45 �  >1500 valid responses �  10 questions

Photo by Ray_from_LA, flickr, 2011

Formula Feeding Was…

Write-in Reasons Given �  Pregnancy �  Sexual assault �  Sleep deprivation �  Sick of breastfeeding �  Breast reduction �  Reflux �  Not allowed to pump at

work �  Embarrassment �  Mother needed more

sleep �  Teething infant/biting �  Thrush/mastitis

�  Failure to thrive �  Adoption �  Lip or tongue tie �  Pressure from family or

doctor �  Painful feeding �  Breast refusal �  Allergies �  Multiples �  IGT/PCOS �  Jaundice �  NICU �  Low blood sugar

“Formula feeding was the last resort that I had with no support.”

Was infant feeding discussed prenatally?

“Once I said I wanted to breastfeed, I was given no other information about breast or formula feeding.”

Were you given information on preparing formula?

The CDC recommends: (from the CDC website as of October 2016)

�  Clean up before preparation �  Wash your hands with soap and water �  Clean bottles in a dishwasher with hot water and a heated drying cycle, or scrub bottles in

hot, soapy water and then sterilize them �  Clean work surfaces, such as countertops and sinks

�  Prepare safely �  Keep powdered formula lids and scoops clean (be careful about what they touch) �  Close containers of infant formula or bottled water as soon as possible �  Use hot water (158 degrees F/70 degrees C and above) to make formula �  Carefully shake, rather than stir, formula in the bottle �  Cool formula to ensure it is not too hot before feeding your baby by running the prepared,

capped bottle under cool water or placing it into an ice bath, taking care to keep the cooling water from getting into the bottle or on the nipple

�  Before feeding the baby, test the temperature by shaking a few drops on your wrist

�  Use up quickly or store safely �  Use formula within 2 hours of preparation. If the baby does not finish the entire bottle of

formula, discard the unused formula. �  If you do not plan to use the prepared formula right away, refrigerate it immediately and

use it within 24 hours. Refrigeration slows bacterial growth and increases safety. �  When in doubt, throw it out. If you can't remember how long you have kept formula in the

refrigerator, it is safer to throw it out than to feed it to your baby.

Were you given information on how much formula to feed your baby?

Write-in comments

�  Formula company can �  Formula company website �  Formula company hotline �  Internet � WIC �  Family � Dietician/Nutritionist

Recommendations from Similac

Research puts breastfed baby intake at 23-30 ounces/day from 1 month – 6

months, and indicates that amounts remain fairly stagnant. (Cox, 1996; Dewey 1983, 1984, 1991; Kent, 1999; Cox 1996; Salazar 2000)

Similac feeding chart, screencap taken from website, 2014

“The information that I got on amounts was conflicting depending on who it was from – sometimes even in the same facility.”

If you supplemented or combo-fed, were you given information on how to successfully manage this?

Write-in comments

• “I was told (to feed formula) as needed. That was never defined.” • “(Combo feeding) was never touted as manageable, so I just switched to formula.” • “I was told to feed until baby wouldn’t take anymore.” • “I was told to give some formula.”

Tarrant et al, 2013, Archives of Disease in Childhood

�  Assessed obesity risk based on formula feeding

�  368 babies �  Available 6 week data (184) showed mean

intake was 205ml/kilogram of body weight/day (so a 10 pound baby would take in about 32 ounces per day)

�  Mothers often switched formula because baby was eating “too often” (defined as 2-3 hours)

Were you given information on types of formula and which would work best for your baby?

Considerations about formula

�  Palm olein oils used in some infant formulas to mimic the fatty acid of human milk has been shown to lower bone mineral content and bone mineral density. Absorption of fat is also negatively effected (Koo et al, 2003, Pediatrics; Koo et al, 2006, Journal of American College of Nutrition)

�  If an infant has a 1st degree relative with allergic disease, avoiding allergens may prevent or delay allergic issues in infant (Greer et al, 2008, Pediatrics)

Prebiotics, Synbiotics, Probiotics and Formula �  “Insufficient data to recommend routine use,” ESPGHAN

Committee on Nutrition, 2011 �  There is not enough evidence to state that supplementation

of term infant formula with synbiotics, probiotics or prebiotics does result in improved growth or clinical outcomes in term infants. There is no data available to establish if synbiotics are superior to probiotics or prebiotics.” Mugambi et al. Nutrition Journal 2012

�  Early prebiotic and probiotic supplementation may alleviate symptoms associated with crying and fussing in preterm infants. Pärtty et al, Journal of Pediatrics, 2013

�  Child care infants fed a formula supplemented with L reuteri or B lactis had fewer and shorter episodes of diarrhea, with no effect on respiratory illnesses. These effects were more prominent with L reuteri, which was also the only supplement to improve additional morbidity parameters. Weizman et al, Pediatrics, 2005

�  Prenatal breastfeeding education �  Classes seem to be most effective (Rosen, 2008)

�  Give bottle feeding education to all bottle feeding mothers, including how to choose the appropriate bottle/nipple ( helpful info from Peterson and Harmer, breastandbottlefeeding.com) �  Exclusively pumping mothers are bottle feeding

�  Give stomach size/appropriate amount information to all mothers �  Teach paced or baby led bottle feeding �  Encourage cue based feeding �  Provide in-depth education on preparation to formula feeding/supplementing families �  Support parents that are formula feeding in choosing a formula, with attention given to

concerns they have or history of allergies �  Teach mothers when to discard prepared formula

�  Refrigerated, premade formula should not be used longer than 24 hours �  Formula remaining after a feed should be discarded

�  Reiterate these points at multiple visits and remind parents that you can help �  If possible, teach not only mother, but significant others and support people �  Supplementing mothers need to be told:

�  How to appropriately mix and store formula or how to appropriately store donor milk if being used

�  Information on keeping a healthy milk supply �  A plan for how much, how often, and how to wean from supplementation (if short

term) �  If mother is exclusively formula feeding, discuss how to dry up breastmilk �  Discourage the “clean plate club,” especially with mothers bottle feeding breastmilk

Recommendations

“ I wish there were a balance between breast and formula feeding. When I ran

into trouble, there was no acceptance that formula was an option, so I continued to

fail and feel worthless while trying to breastfeed. There is no support for those struggling if they don't respond to the ‘it

gets better’ mantra. I wanted to die because I was a failure at breastfeeding.”